There is definitely a time and a place, a reason and a need for people to take medications. However, there is also an epidemic of over-prescribing and abusing them. Conscientious use is key for people who wish to age well.
Drugs? Medications? OTC drugs? Prescriptions? Illegal drugs? What are we talking about? According to the FDA, “a drug is a substance intended for use in the diagnosis, cure, mitigation, treatment, or prevention of disease.” All medicines are drugs, but all drugs are not medicines. The government and the law determines the line between the two.
Drugs are prescribed for medicinal purposes by a doctor or obtained over the counter (OTC) at a pharmacy. They are also bought illegally when forbidden by the law.
Sometimes a drug is both legal and illegal. For instance, “Opioids are a class of drugs that include the illegal drug heroin, synthetic opioids such as fentanyl, and pain relievers available legally by prescription.” Marijuana is another example. Doctors prescribe medical marijuana and people are arrested for using it recreationally in some states.
This newsletter focuses on drugs prescribed for medicinal purposes by a doctor. It briefly touches on topics you may not be aware of. I sure wasn’t. Topics such as how drugs are marketed to doctors, the effect of drugs on older adults, the prescribing of multiple drugs, the role of advertising, and the possibility of addiction.
MARKETING TO DOCTORS
John Oliver, host of the HBO show Last Week Tonight, describes the first topic well in his YouTube video Marketing to Doctors. Take a few minutes to hear his message.
EFFECT ON OLDER ADULTS
Typically, older people take more drugs than younger people because they have more than one chronic medical disorder. They may also have been taking drugs for years. According to Kaiser Health News, though:
For decades, experts have warned that older Americans are taking too many unnecessary drugs, often prescribed by multiple doctors, for dubious or unknown reasons. Researchers estimate that 25 percent of people ages 65 to 69 take at least five prescription drugs to treat chronic conditions, a figure that jumps to nearly 46 percent for those between 70 and 79. Doctors say it is not uncommon to encounter patients taking more than 20 drugs to treat acid reflux, heart disease, depression, insomnia, or other disorders.
The glide path to overuse can be gradual. A patient taking a drug to lower blood pressure develops swollen ankles, so a doctor prescribes a diuretic. The diuretic causes a potassium deficiency, resulting in a medicine to treat low potassium. But that triggers nausea, which is treated with another drug, which causes confusion, which in turn is treated with more medication.
In the July newsletter, Had I Only Known, I wrote about the effect that hospitalization, anesthesia, and medications had on my husband as he battled dementia and COVID.
The following list is a useful guideline when deciding whether or not certain prescriptions are appropriate for an older person. Yet, none of them were discussed with us during his hospital stays. For example:
Potential harm and benefits of a given medication. No one mentioned that anesthesia might increase memory problems.
Review of prescriptions and assessment of the risk/benefit balance. No one asked what medications he was already on.
Consider non-pharmacological treatments for common symptoms like dizziness, insomnia, and headaches. The only solution offered was more drugs.
Psychological factors such as recent bereavement and social isolation should be considered and addressed. He was a hypochondriac and had many unfounded health issues. No one considered that possibility.
Consider whether it is appropriate in the context of the whole person, the risks of taking the medication, the likelihood of compliance, and the population from which the original evidence of effectiveness was identified. No one discussed possible risks.
The lesson to be learned: know what medications are prescribed and ask a lot of questions. In retrospect, I didn’t ask enough.
Polypharmacy is the simultaneous use of multiple medications. While this may not seem like a bad thing, taking too many exposes a person to many side effects at the same time. This concern applies to mixtures of prescriptions, over-the-counter (OTC) drugs, and dietary supplements, as well.
Studies have linked polypharmacy to unnecessary deaths.
Pooled risk estimates from this meta-analysis reveal that polypharmacy is associated with increased mortality risk, using both discrete and categorical definitions. The causality of this relationship remains unclear, but it emphasizes the need for approaches to health care delivery that achieve an optimal balance of risk and benefit in medication prescribing.
Older patients, who have greater difficulty metabolizing medicines, are more likely to suffer dizziness, confusion, and falls. Often drug side effects are misinterpreted as a new problem, triggering more prescriptions. Multiple prescriptions can lead to a “prescribing cascade.”
The Aging Care Website describes the cascade well.
Research shows that the average older adult takes four or more prescription drugs each day, but 39 percent of seniors take five or more prescriptions each day. While each one was created to treat or manage a specific medical problem, each one also comes with its own risks and side effects.
The more medications a person takes, the higher the chances are for experiencing adverse reactions, negative side effects and even life-threatening conditions. Overall, polypharmacy in the elderly is a major contributor to disability, frailty, falls, long-term care placement, and a decreased quality of life.
The lesson to be learned: take medications only when necessary.
You can't watch a sporting event without seeing an ad for treating erectile dysfunction, high cholesterol, high blood pressure, or joint pain. Also true, the cost of a 30 second spot for a 2021 Super Bowl commercial was $5,500,000.
The Harvard Health Publishing website notes:
Drug marketing is big business, and companies are willing to spend a lot of money to offer you an easy solution to a health problem you may or may not have. From 2012 to 2015, yearly spending on prescription drug advertising in all media outlets (except digital) rose from $3.2 billion to $5.2 billion, and that figure is expected to only go up.
The results of a pilot study discussed in The National Institution of Health note that certain themes emerged from direct-to-consumer advertising (DTCA). One interesting theme was that awareness of medications increased. A second interesting theme was that because of missing or misleading information, drugs were often perceived as being more effective than clinical evidence suggested.
Advertising can lead to doctor shopping: “obtaining controlled substances from multiple healthcare practitioners without their knowledge of other prescriptions.” Patients manipulate the system to get extra drugs.
Doctor shopping involves visiting multiple doctors and providing false information to obtain multiple prescriptions. People lie about symptoms, deny receiving previous medications, omit information, purposely injure themselves, claim they lost previous prescriptions, or commit other forms of deception.
This short YouTube video exemplifies the issue:
A doctor friend tells the story of her patients who doctor shop. If she doesn’t provide the prescription they want, they find someone who will.
The lesson to be learned: don’t believe everything you read.
ABUSE AND ADDICTION
While most individuals who are prescribed a medication follow the direction of their physician, use the medication as directed, and stop the medication at the appropriate time, there is also a risk of addiction or misuse associated with prescription drugs.
Users discover that a prescribed medication causes them to experience ‘pleasant’ feelings they don’t want to give up. They crave the effects of the prescription drug, both physically and psychologically, and begin to use it in ways that weren’t prescribed. The most commonly abused prescription drugs are opioid painkillers, anti-anxiety agents, sedatives, and stimulants.
After breaking my arm, I was given a prescription for pain. With no medication, the pain returned and there was depression. Those symptoms disappeared in a few days, but the outcome could have been different had I made other choices.
According to the National Library of Health:
One-quarter of the prescription drugs sold in the United States are used by the elderly, often for problems such as chronic pain, insomnia, and anxiety. The prevalence of abuse may be as high as 11 percent with female gender, social isolation, depression, and history of substance abuse increasing risk.
Screening instruments for prescription drug abuse have not been validated in the geriatric population. Benzodiazepines, opiate analgesics, and some skeletal muscle relaxants may result in physical dependence; however, tolerance, withdrawal syndrome, and dose escalation may be less common in older patients.
This increase is driven by opioid misuse. True, older and younger adults are vulnerable, but it is also driven by the unique challenges of pain management in an aging population.
Up to this point, though, researchers have been unable to determine an exact reason for the development of prescription addiction.
Lesson learned: Be aware!
The Rebound Effect and Habituation
Two side effects of taking drugs whether prescribed by a doctor or bought at a pharmacy are the rebound effect and habituation.
The rebound effect is the increased production of negative symptoms as the drug’s effect decreases and the person no longer responds to it. The condition being treated tends to come back stronger and the drug loses its effectiveness. So, the inclination is to keep taking the drug, or more of it, to avoid the discomfort.
Habituation is the process whereby the body becomes used to a certain amount of a drug and needs more to make a difference. Tolerance to the effects of a drug is acquired through continued use and there is a decrease in responsiveness upon repeated exposure to the drug.
I had migraine headaches and was prescribed medication. It worked really well the first few times, but very soon I had to take more, more often, to manage the headaches.
Today, I take supplements and a couple of over the counter drugs, but no prescription medications. Hopefully, that will remain the case for a long while.
The bottom line is that a strategy for aging well is to know about and carefully manage the drugs you take. It really is up to you.